Diagnostic accuracy of autofluorescence-Raman spectroscopy for surgical margin assessment during Mohs micrographic surgery of basal cell carcinoma.

BACKGROUND: Autofluorescence (AF) - Raman spectroscopy is a technology that can detect residual basal cell carcinoma (BCC) on the resection margin of fresh surgically excised tissue specimens. The technology does not require tissue fixation, staining, labelling, or sectioning, and provides quantitative diagnosis maps of the surgical margins in 30 minutes. OBJECTIVES: To determine the accuracy of the AF-Raman instrument to detect incomplete excisions of BCC during Mohs micrographic surgery, using histology as reference standard. METHODS: Skin layers from 130 patients undergoing Mohs surgery at the Nottingham University Hospitals NHS Trust (September 2022 to July 2023) were investigated with the AF-Raman instrument. The layers were measured fresh, immediately after excision. The AF-Raman results and the intra-operative assessment by Mohs surgeons were compared to a post-operative consensus-derived reference produced by three dermatopathologists. The sensitivity, specificity, positive predictive value, and negative predictive value were calculated. RESULTS: The AF-Raman analysis was successfully completed for 125 out of the 130 layers. The AF-Raman analysis covered 91% of the specimen surface area on average, with the lowest being 87% for eyelid and the highest being 94% for forehead specimens. The AF-Raman instrument identified positive margins in 24 out of 36 BCC-positive cases, resulting in a 67% sensitivity (95% confidence intervals (CI): 49%-82%) and negative margins in 65 out of 89 BCC-negative cases, resulting in a 73% specificity (95% CI 63%-82%). Only one out of the 12 false negative cases was caused by misclassification by the AF-Raman algorithm. The other 11 false negatives cases were produced because no valid Raman signal was recorded at the location of the residual BCC due to either occlusion by blood or poor contact between tissue and cassette window. The intra-operative diagnosis by Mohs surgeons identified positive margins in 31 out of 36 BCC-positive cases, 86% sensitivity (95% CI: 70%-95%), and negative margins in 79 out of 89 BCC-negative cases, 89% specificity (95% CI: 81%-95%). CONCLUSIONS: This study shows that the AF-Raman instrument has potential for intra-operative microscopic assessment of surgical margins in surgery of BCC. Further improvements are required for tissue processing to ensure complete coverage of the surgical specimens. ClinicalTrials.gov ID NCT03482622.

A UK-wide study to describe resource consumption and waste management practices in skin surgery including Mohs micrographic surgery.

BACKGROUND: There is a lack of national guidance specifying how skin surgery, including Mohs micrographic surgery (MMS), should be conducted, leading to a degree of heterogeneity in the set-up of skin surgery services and how skin surgeries are performed. OBJECTIVES: To provide the first UK-wide cross-sectional study reporting real-world data on the set-up and waste management practices of skin surgery, including MMS. METHODS: A UK-wide service evaluation study was conducted between 1 March 2022 and 30 June 2022 using a standardized data collection pro forma. Twelve participating sites from England, Northern Ireland, Scotland and Wales provided data from 115 skin surgery lists involving 495 patients and 547 skin surgery procedures between 1 March 2022 and 30 June 2022. RESULTS: Mean total weight of nonsharps skin surgery waste was 0.52 kg per procedure (0.39 kg clinical waste, 0.05 kg general waste and 0.08 kg recycling waste). Data from a single site using disposable surgical instruments reported a mean of only 0.25 kg of sharps waste per procedure. The recycling rate ranged between 0% and 44% across the cohort with a mean recycling rate of 16%. CONCLUSIONS: We advocate that staff transition to the British Society of Dermatological Surgery 2022 sustainability guidance, which made wide-ranging recommendations to facilitate staff to transition to sustainable practices in skin surgery.

Anti-NMDA-receptor encephalitis presenting with catatonia and neuroleptic malignant syndrome in patients with intellectual disability and autism.

We report anti-N-methyl-d-aspartate (NMDA) receptor encephalitis in two patients with autism and intellectual disability presenting with neuropsychiatric symptoms of catatonia and neuroleptic malignant syndrome. Case reports such as these help raise awareness of this clinical issue. By paving the way for earlier diagnoses they ultimately maximise the potential for curative treatments and prevention of long-term complications.

A new oxygen prescription produces real improvements in therapeutic oxygen use.

In the UK, safe use and administration of oxygen therapy was unsatisfactory prior to the implementation of national guidelines in 2008. Each year since then the British Thoracic Society (BTS) has conducted a national audit that has demonstrated a slow but steady improvement in oxygen use across four key standards. Sandwell and West Birmingham NHS Hospitals Trust has participated in this audit process but has failed to show consistent improvements. The aim of this quality improvement project was to produce meaningful and sustained improvements in oxygen use across each of the four standards. Four interventions were developed over three PDSA cycles and included: 1. a new oxygen prescription chart, 2. oxygen 'alert' stickers for use on drug and MEWS charts, 3. point of care resources, and 4. senior led educational sessions for healthcare staff. Each intervention was tested on the Acute Medical Unit over seven days and data collected using the BTS data collection form. The QIP improved oxygen use across each of the standards: baseline measurement for standard one demonstrated that 55% of patients using oxygen had a valid oxygen prescription, improving to 94% after PDSA cycle three. For standard two, baseline measurement demonstrated that 50% of patients had a documented oxygen target saturation range, improving to 94% after PDSA cycle three. For standard three, baseline measurement demonstrated that 84% patients using oxygen had saturations documented on the MEWS chart, improving to 100% after PDSA cycle three. Finally, baseline measurement of standard four demonstrated that 0% patients with a valid oxygen prescription had it signed for at drugs rounds, improving to 18% after PDSA cycle three. Oxygen use was substantially improved during the QIP. Following engagement with stakeholders a new oxygen prescription will be rolled out within the Trust with projected annual savings of £30,400.